THE FLORIDA WORKERS’
COMPENSATION SYSTEM
TUTORIAL
for
EXPERT MEDICAL ADVISORS
This tutorial will provide the reader with
highlights from each of the pertinent
medical sections of the Florida Statutes.
The Department of Financial Services’ - Division
of Workers’ Compensation’s internet site offers a
complete copy of Chapter 440, F.S. on the home
web page: http://www.fldfs.com/wc.
(Click on “Ch. 440 FL Statutes” located in the
topics listed on the left side of the home page.)
Through this program…
THE EXPERT MEDICAL ADVISOR WILL BE ABLE
TO UNDERSTAND HIS/HER RESPONSIBILITIES
FOR PROVIDING EXPERT OPINION TO FACILITATE
THE RESOLUTION OF MEDICAL CARE ISSUES
AND DISPUTES PENDING BEFORE THE DIVISION
OR A JUDGE OF COMPENSATION CLAIMS
The Florida Workers’
Compensation System Goals
provide for the following:
 A Self Executing System
 Quick Efficient Delivery of
Medical Benefits
 Medically Necessary Treatment
 Facilitation of Return to Work
WHAT ARE WORKERS’
COMPENSATION BENEFITS?
• MEDICAL MEDICALLY NECESSARY
MEDICAL CARE
• INDEMNITY WAGE REPLACEMENT BENEFITS
• REEMPLOYMENT VOCATIONAL REHABILITATION
BENEFITS TO FACILITATE EARLY
RETURN TO SUITABLE GAINFUL
EMPLOYMENT
WHAT IS THE ROLE OF THE PHYSICIAN
WHO RENDERS CARE AND SERVICES
TO INJURED WORKERS IN THE
FLORIDA WORKERS’ COMPENSATION
SYSTEM?
THE ROLE OF THE PHYSICIAN
TO ESTABLISH AN ACCURATE DIAGNOSIS
The Clinical Evaluation must be based on
History/Physical/Diagnostics, Diagnosis & Treatment,
Studies and Consultations
TO PRESCRIBE “MEDICALLY NECESSARY” TREATMENT
Definition - s.440.13(1)(m), F.S.
The Proposed Treatment Plan MUST BE submitted on
Form DFS-F5-DWC-25 (DWC-25)
TO COMMUNICATE THE PATIENT’S FUNCTIONAL STATUS
Identify Medical Restrictions/Limitations relating to work & full
time or transitional duty
Prescribe Restrictions/Limitations and submit to the insurer
on DWC-25
STANDARDS OF CARE
s.440.13(16), F.S.
The health care provider’s care and treatment shall
be based on the following standards of care.
 Treatment is inherently scientifically logical
 Treatment focuses on clinical dysfunction
 High intensity, short duration treatment approach
 Treatment plan, therapies, medication, functional
limitations/restrictions periodic review
 Additionally, the treatment plan is reviewed upon
receiving information from other health care
providers [no less than] every 30 days
STANDARDS OF CARE
(continued)
s.440.13(16), F.S.
 Treatment MATCHES physiologic and clinical problem
 Treatment SHALL match type, intensity, duration of
service necessary for identified problem
 Restrictions / Limitations are based on objective
RELEVANT medical findings
 Restrictions / Limitations are reviewed continuously
and at EACH and EVERY visit
 Return to work (RTW) is an integral part of the
treatment plan
THE ROLE OF THE PHYSICIAN
(continued)
WHEN PROVIDING SPECIFIC LIMITATIONS / RESTRICTIONS
The health care provider shall identify:
 Specific Parameters (i.e. load, frequency, duration,





position)
Measured inabilities
Detriments to recovery
Imminent danger to self or others
Alternative methods of function
THE HEALTH CARE PROVIDER IS TO IDENTIFY
THE EMPLOYEE’S PHYSICAL LIMITATIONS, AND
ADDRESS RETURN TO WORK STATUS
STANDARDS OF CARE
(continued)
s.440.13(16), F.S.
The Standards of Care shall be followed in providing
medical care under Chapter 440:
(a) Abnormal anatomical findings alone, in the
absence of objective relevant medical
findings, shall not be an indicator of injury or
illness, a justification for the provision of
remedial medical care or the assignment of
restrictions, or the foundation for limitations.
STANDARDS OF CARE
(continued)
s.440.13(16), F.S.
(b) At all times during evaluation and treatment,
the provider shall act on the premise that
returning to work is an integral part of the
treatment plan.
The assignment of restrictions and limitations
shall be reviewed with each patient exam and
upon receipt of new information…

The health care provider shall
report changes in restrictions and
limitations on the Form DWC-25.
STANDARDS OF CARE
(continued)
s.440.13(16), F.S.
(c) Reasonable, necessary medical care of injured
employees shall in all situations:
1. Utilize a high intensity, short duration
treatment approach
2. Include reassessment of treatment plans,
regimes, therapies, prescriptions, and functional
limitations or restrictions prescribed by the
provider every 30 days
3. Be focused on treatment of the individual
employees specific clinical dysfunction or status
STANDARDS OF CARE
(continued)
s.440.13(16), F.S.
All treatment shall be inherently scientifically logical,
and the evaluation or treatment procedure must match
the documented physiologic and clinical problem.
Treatment shall match the type, intensity, and duration
of service required by the problem identified.
 The carrier may disallow
reimbursement for a procedure
when the treatment procedure does
not match the problem identified.
THE ROLE OF THE PHYSICIAN
(continued)
TO ESTABLISH THE DATE OF MAXIMUM MEDICAL MPROVEMENT
MMI is reached when no further recovery is anticipated
or when maximum improvement is a reasonable medical
probability [s.440.02(10), F.S.]
TO DOCUMENT THE PERMANENT IMPAIRMENT RATING (PIR)
The physician shall:

calculate PIR at the time of MMI

identify anatomical/functional abnormalities or losses
resulting from work-related injury or illness

identify the injured workers’ permanent
restrictions/limitations
PERMANENT IMPAIRMENT RATING
s.440.15(3)(b), F.S.
Pursuant to the Florida Statutes, only physicians
licensed under Florida Statute Chapters, as appropriate
(considering the nature of the injury), are authorized to
render an opinion regarding the permanent impairment
rating of an injured employee:
458 Medical
469 Osteopathic
460 Chiropractors 461 Podiatrists
463 Optometrists
466 Dentists
TEMPORARY TOTAL DISABILITY
s.440.15(2)(a), F.S.
When does the healthcare provider assign MMI & PIR?
“…once the employee reaches the maximum number
of weeks allowed, or the employee reaches the date
of maximum medical improvement, whichever occurs
earlier, temporary disability benefits shall cease and
the injured worker’s permanent impairment shall be
determined.”
 Once the physician determines the employee
has achieved maximum medical improvement,
the physician SHALL calculate the permanent
impairment rating.
PERMANENT IMPAIRMENT RATING
s.440.15(3)(d), F.S.
After the employee has been certified by a
doctor as having reached maximum medical
improvement… the certifying doctor shall
evaluate the condition of the employee and
assign an impairment rating, using the
impairment schedule on the following slide.
 Maximum medical improvement and
impairment rating shall be reported by the
physician to the carrier on the Form DWC-25.
PERMANENT IMPAIRMENT RATING/
MAXIMUM MEDICAL IMPROVEMENT
s.440.15(3)(d)1., F.S.
“The certifying doctor shall issue a written report to the
employee and the carrier certifying that maximum medical
improvement has been reached…and providing any other
information required by the department by rule.”
(report MMI/PIR on Form DWC-25, specifying permanent
restrictions / limitations pursuant to 69L-7.602, F.A.C.)
“The carrier shall establish an overall
maximum medical improvement date
and permanent impairment rating,
based on all such reports.”
PERMANENT IMPAIRMENT RATING
s.440.15(3)(d), F.S.
If the certification and evaluation are performed by a
doctor other than the employee’s treating doctor, the
certification and evaluation must be submitted to the
treating doctor, the employee, and the carrier within
10 days after the evaluation. The treating doctor
must indicate to the carrier agreement or
disagreement with the other doctor’s certification and
evaluation.
 The certifying doctor who is not the employee’s
treating doctor must submit a completed Form
DWC-25 to the treating doctor, the employee and
the carrier within 10 days after the evaluation.
SUBSEQUENT INJURY;
APPORTIONMENT
s.440.15(5)(b), F.S.
The degree of permanent impairment or disability
attributable to the accident or injury shall be
compensated in accordance with this section,
apportioning out the preexisting permanent
condition based on the anatomical impairment
rating attributable to the preexisting condition.
RATING PERMANENT IMPAIRMENT
s.440.15(3)(b), F.S.
The health care provider shall use the following resources
to calculate a permanent impairment rating (based on the
date of injury or accident – DOI):
•
AMA, 3RD EDITION
for DOI: prior to 07/01/90
• MINNESOTA GUIDE
for DOI: 07/01/90 to 06/20/93
• 1993 Florida Impairment
Rating Guide (FIRG)
for DOI: 06/21/93 to 01/07/97
• 1996 FL Uniform P.I.R.
Schedule
for DOI: 01/08/97 and thereafter
Florida Statutes
Chapter 440, Florida Statutes, identifies the
employer, health care provider and insurer/
carrier duties and responsibilities related to
the provision of care for Florida injured
workers. The health care provider should
review the following excerpts to be familiar
with the Florida Statutes pertaining to
medical services.
Florida Statutes
•
•
•
•
440.02
440.09
440.093
440.102
• 440.105
• 440.13
Definitions.
Coverage.
Mental and nervous injuries.
Drug-free workplace program
requirements.
Prohibited activities; reports;
penalties; limitations. (Fraud)
Medical services and supplies;
penalty for violations; limitations
Florida Statutes
• 440.134
Workers’ compensation managed
care arrangement
• 440.15(3) Permanent impairment benefits/
rating
• 440.15(5) Subsequent injury; apportionment
• 440.151
Occupational diseases
• 440.20
Time for payment of compensation
and medical bills; penalties for late
payment
• 440.491
Reemployment of injured workers;
rehabilitation
Florida Statutes s.440.02
Definitions
(10) “Date of maximum medical improvement”
means the date after which further recovery
from, or lasting improvement to, an injury or
disease can no longer reasonably be
anticipated, based upon reasonable medical
probability.
(15)(a) Employee – means any person who receives
remuneration from an employer for the
performance of any work or service while
engaged in any employment …and includes, but
is not limited to, aliens and minors.
Florida Statutes s.440.09
Coverage
The following factors impact whether an injury or illness
is compensable under Florida’s workers’ compensation.
(1) Major Contributing Cause – means the cause which is
more than 50% responsible for the injury as compared to
all other causes combined for which treatment or benefits
are sought.
(1) Pain or other subjective complaints alone, in the
absence of objective relevant medical findings, are not
compensable.
(1) Objective relevant medical findings are those objective
findings that correlate to the subjective complaints of the
injured employee and are confirmed by physical
examination findings or diagnostic testing.
Florida Statutes s.440.09
Coverage (continued)
(1)(a) Subsequent Injury – No compensation or
benefits for any subsequent injury the employee
suffers as a result of an original work injury unless
the original injury is the major contributing cause of
the subsequent injury.
(1)(b) If a work injury combines with a preexisting
disease or condition to cause or prolong disability
or need for treatment, the employer must pay
compensation or benefits only to the extent that the
work injury remains more than 50% responsible for
the injury as compared to all other causes
combined.

MAJOR CONTRIBUTING CAUSE must be
demonstrated by medical evidence only.
Florida Statutes s.440.09
Coverage (continued)
(3)
Compensation is not payable if the injury was
occasioned primarily by the intoxication of the
employee; by the influence of any drugs not
prescribed by a physician; or by the willful intention
of the employee to injure or kill himself, herself, or
another.
(7)(c) If the injured worker refuses to submit to a
drug test, it shall be presumed in the absence of
clear and convincing evidence to the contrary that
the injury was occasioned primarily by the influence
of drug.
Review of Coverage
s.440.09(1)(a)(b), F.S.

The treatment must be based on objective
RELEVANT medical findings

The work-related injury must be the MAJOR
CONTRIBUTING CAUSE

The diagnosis must be determined by
MEDICAL EVIDENCE only

Pain and/or a subjective complaint without
objective RELEVANT medical findings is
NOT COMPENSABLE
Florida Statutes s.440.093
Mental and nervous injuries
(1) A mental or nervous injury due to stress, fright, or
excitement only is not an injury by accident arising
out of the employment. A physical injury resulting
from mental or nervous injuries unaccompanied by
physical trauma requiring medical treatment shall
not be compensable under this chapter.
(2) Mental and nervous injuries occurring as a
manifestation of an injury compensable under this
chapter shall be demonstrated by clear and
convincing medical evidence…The compensable
physical injury must be and remain the major
contributing cause…Compensation is not payable
for the mental, psychological or emotional injury
arising out of depression…
Florida Statutes s.440.093
Mental and nervous injuries (cont.)
(3) Subject to the payment of permanent benefits
under s.440.15, in no event shall temporary
benefits for a compensable mental or nervous
injury be paid for more than 6 months after the
date of maximum medical improvement for the
injured employee’s physical injury or injuries…
Florida Statutes s.440.102
Drug-free workplace program requirements
(1)(c) “Drug” means alcohol, including a distilled
spirit, wine, a malt beverage or an intoxicating
liquor; an amphetamine; a cannabinoid;
cocaine; phencyclidine (PCP); a hallucinogen;
methaqualone; an opiate; a barbiturate ; a
benzodiazepine; a synthetic narcotic; a
designer drug; or a metabolite of any of the
substances listed. An employer may test an
individual for any or all of such drugs.
Florida Statutes s.440.102
Drug-free workplace program requirements
(5)(e)2. A specimen for a drug test may be taken or
collected by …a physician, a physician
assistant, a registered professional nurse, a
licensed practical nurse, or a nurse practitioner
or a certified paramedic who is present at the
scene of an accident for the purpose of
rendering emergency medical service or
treatment.
(5)(m) An employer shall pay the cost of all drug
tests, initial and confirmation, which the
employer requires of employees. An
employee or job applicant shall pay the costs of
any additional drug tests not required by the
employer.
Florida Statutes s.440.102
Drug-free workplace program requirements
(5)(p) All authorized remedial treatment, care and
attendance provided by a health care provider to
an injured employee before medical and
indemnity benefits are denied under this section
must be paid for by the carrier or self-insured.
However, the carrier or self-insurer must have given
reasonable notice to all affected health care
providers that payment for treatment, care and
attendance provided to the employee after a future
date certain will be denied.
Florida Statutes s.440.105
Prohibited activities; reports;
penalties; limitations
(1)(a) …any professional practitioner licensed or
regulated by the Department of Health…or any
employee thereof, having knowledge or who
believes that a fraudulent act or any other act or
practice which, upon conviction, constitutes a
felony or misdemeanor under this chapter is being
or has been committed shall send to the Division
of insurance Fraud, Bureau of Workers’
Compensation Fraud, a report or information
pertinent to such knowledge or belief and such
additional information relative thereto as the
bureau may require.
Florida Statutes s.440.105
Prohibited activities; reports;
penalties; limitations
(4)(c) It shall be unlawful for any physician licensed
under chapter 458, osteopathic physician licensed
under chapter 469L, chiropractic physician
licensed under chapter 460, podiatric physician
licensed under chapter 461, optometric physician
licensed under chapter 463, or any practitioner
licensed under the laws of this state to knowingly
and willfully assist, conspire with, or urge any
person to fraudulently violate any of the provisions
of this chapter.
Florida Statutes s.440.105(7)
Fraud Statement
Fraud Statement - An injured employee or any other
party making a claim under this chapter shall provide
his or her personal signature attesting that he or she
has reviewed, understands, and acknowledges the
following statement:
“Any person who, knowingly and with
intent to injure, defraud, or deceive any
employer or employee, insurance
company, or self-insured program, files a
statement of claim containing any false or
misleading information commits insurance
fraud, punishable as provided in s.
817.234.”
Florida Administrative Code
Rule 69L-3.0047, F.A.C.
Fraud Statement
(2) A party who makes claims for services provided to
the claims-handling entity on a recurring basis
may make one personally signed attestation to
the claims-handling entity as required by Section
440.105(7), F.S., which will satisfy the
requirement for all claims submitted to the
claims-handling entity for the calendar year in
which the attestation is submitted.
 Health Care Providers must submit a signed fraud
statement once per calendar year to each insurer /
carrier from which they are requesting reimbursement.
Florida Statutes 440.105(7)
Fraud Statement
If the injured employee or other party refuses to sign
the document attesting that he or she has reviewed,
understands, and acknowledges the statement,
benefits, or payments under this chapter shall be
suspended until such signature is obtained.
 The insurer may disallow payment for a medical
bill if the health care provider fails to have a
signed Fraud Statement on file with the insurer.
Florida Statutes 440.13
Medical Services
Each subsection of the following Florida
Statutes is presented in detail to familiarize
the health care provider with the Florida
Statutes pertinent to treatment rendered to
injured workers in the Florida Workers’
Compensation system.
Florida Statutes 440.13
Medical Services
DEFINITIONS
• 440.13(1)(d): Health care provider certification
• 440.13(1)(h): Health care provider who renders
care pursuant to a prescription or
under the supervision of a
physician
• 440.13(1)(l): Medical necessity
• 440.13(1)(q): Physician
Florida Statutes 440.13
Medical Services
• 440.13(2)(d): Carrier right to transfer care
• 440.13(3)(a): Provider certification; Authorization
prior to provision of care
• 440.13(3)(b): Emergency care; authorization
• 440.13(3)(c): Provider referrals
• 440.13(3)(g): Employee liability for payment
Florida Statutes 440.13
Medical Services
• 440.13(3)(d) & (i): Carrier authorization
• 440.13(4)(a): Form DFS-F5-DWC-25
• 440.13(4)(b) Provision of medical records
• 440.13(4)(c): Physician-patient privilege
• 440.13(5)(a): Independent medical
examinations (IME)
Florida Statutes 440.13
Medical Services
• 440.13(5)(d): IME No-show provisions
• 440.13(7)(a): Reimbursement disputes
• 440.13(8)(b) Overutilization; statute or rule
violations; health care provider
penalties/sanctions
• 440.13(9):
Expert Medical Advisors
• 440.13(10):
Witness (deposition) fees
Florida Statutes 440.13
Medical Services
• 440.13(12):
Reimbursement allowances
• 440.13(13):
Removal of physicians from the list
of certified health care providers
• 440.14(14)(c): Co-payment after assignment of
MMI
• 440.13(15):
Practice Parameters
• 440.13(16):
Standards of Care - reasonable
necessary medical care
Florida Statutes 440.13(1)
Definitions
(c) “Carrier” means, for purposes of this section, insurance
carrier, self-insurance fund or individually self-insured
employer, or assessable mutual insurer.
(d) “Certified health care provider” means a health care
provider who has been certified by the Division or who
has entered an agreement with a licensed managed care
organization to provide treatment to injured workers
under this section. Certification of such health care
provider must include documentation that the health care
provider has read and is familiar with the portions of the
statute, impairment guides, practice parameters,
protocols of treatment, and rules which govern the
provision of remedial treatment, care, and attendance.
Florida Statutes 440.13(1)
Definitions
(h) “Health care provider” means a physician or any
recognized practitioner who provides skilled services
pursuant to a prescription or under the supervision or
direction of a physician and who has been certified by
the Division as a health care provider…
(l) “Medically necessary” or “medical necessity” means
any medical service or medical supply which is used to
identify or treat an illness or injury, is appropriate to the
patient’s diagnosis and status of recovery, and is
consistent with the location of service, the level of care
provided, and applicable practice parameters…The
service must not be of an experimental, investigative,
or research nature.
Florida Statutes 440.13(1)
Definitions
(o) “Pattern or practice of overutilization” means repetition
of instances of overutilization within a specific medical
case or multiple cases by a single health care provider.
(q) “Physician” or “doctor” means a physician licensed
under chapter 458, an osteopathic physician licensed
under chapter 469L, a chiropractic physician licensed
under chapter 460, a podiatric physician licensed
under chapter 461, an optometrist licensed under
chapter 463, or a dentist licensed under chapter 466,
each of whom must be certified by the Division…
(r) “Reimbursement dispute” means any disagreement
between a health care provider or health care facility
and carrier concerning payment for medical treatment.
CARRIER TRANSFER OF CARE
s.440.13(2)(d), F.S.
The carrier has the right to transfer the care of
an injured employee from the attending health
care provider if an independent medical
examination determines that the employee is
not making appropriate progress in recuperation.
CERTIFICATION & INSURER
AUTHORIZATION
Non-Emergency Care
s. 440.13(3)(a), F.S.
Conditions of eligibility for reimbursement
The health care provider must have:


Certification from the Division and
Insurer/Carrier authorization prior to
provision of services
Notice of Injury: Filing the DWC-1 is the
responsibility of the Employer.
CERTIFIED HEALTH CARE PROVIDER
“Certified Health Care Provider” means a health
care provider who has been certified by the
Division or who has entered an agreement with a
licensed managed care organization to provide
treatment to injured workers under Chapter 440,
pursuant to s.440.13(1)(d), Florida Statutes.”
CERTIFIED HEALTH CARE PROVIDER
How does a physician become a
“Certified Health Care Provider”?
 The physician must meet the qualifications specified
in Rule 69L-29, F.A.C.
 The physician must submit an accurately completed
application for Health Care Provider Certification to
the Division
The application may be printed from the following link:
http://www.fldfs.com/wc/pdf/DFS-3160-0020.pdf
CERTIFICATION & INSURER
AUTHORIZATION
EMERGENCY CARE
s.440.13(3)(b), F.S.
For emergency care & services:
 Pre-authorization & use of a
certified HCP is not required
 The HCP must notify the carrier by
close of 3rd business day
 The treatable condition must arise
from work-related accident
+
Emergency is defined. . .
 In s. 395.002(9), F.S.
 As an acute, severe (includes pain),
causes impairment, death, or dysfunction
 And covers screening, exam, evaluation,
care, treatment, or surgery to relieve /
alleviate symptoms
EXPERIMENTAL, INVESTIGATIVE OR
RESEARCH IN NATURE
How does a health care provider gain approval
for treatment that may be deemed experimental,
investigative or research in nature?
Effective October 1, 2003, the insurer / carrier has
statutory authority to determine if a treatment procedure is
experimental, investigative or research in nature.
Effective October 1, 2003, all requests for determination of
coverage for treatment procedures that may be
experimental, investigative or research in nature shall be
submitted by the health care provider to the carrier.
PROVIDER REFERRALS
s.440.13(3)(c),F.S.
“A health care provider may not refer the
employee to another health care provider,
diagnostic facility, therapy center, or other
facility without prior authorization from the
carrier, except when emergency care is
rendered. “
 Referrals must be made to another certified
health care provider, unless the referral is
for emergency treatment.
EMPLOYEE LIABILITY
FOR PAYMENT
Can the injured employee be billed for services
provided in relation to a compensable work injury?
“The employee is not liable for payment of
medical treatment or services provided pursuant
to this section except as otherwise provided in
this section. “ s.440.13(3)(g), F.S.
)
“…providers have recourse against the employer
or carrier for payment for services rendered in
accordance with this chapter.” s.440.13(14)(a), F.S.
PAYMENT OF MEDICAL FEES
s.440.13(14)(a), F.S.
“ Except for emergency care treatment, fees for
medical services are payable only to a health care
provider certified and authorized to render remedial
treatment, care or attendance under this chapter…
A health care provider may not collect or receive a
fee from an injured employee within this state,
except as otherwise provided by this chapter…
Such providers have recourse against the employer
or carrier for payment for services rendered in
accordance with this chapter.”
PAYMENT OF MEDICAL FEES
Patient Copayment
s.440.13(14)(c), F.S.
When may the healthcare provider collect
payment from the injured employee?
“ Notwithstanding any other provision of this
chapter, following overall maximum medical
improvement from an injury compensable under
this chapter, the employee is obligated to pay a
copayment of $10 per visit for medical services.
The copayment shall not apply to emergency
care provided to the employee.”
SUBSEQUENT INJURY;
APPORTIONMENT
s.440.15(5)(b), F.S.
“If a compensable injury, disability, or need for medical
care, or any portion thereof, is a result of aggravation or
acceleration of a preexisting condition, or is the result of
merger with a preexisting condition, only the disabilities
and medical treatment associated with such compensable
injury shall be payable under this chapter…”
 The carrier may reduce reimbursement for medical
services by the percentage of impairment or
disability attributed to the preexisting condition.
OCCUPATIONAL DISEASES
s.440.151(1)(a), F.S.
…in no case shall an employer be liable for
compensation under the provisions of this section
unless such disease has resulted from the nature
of the employment in which the employee was
engaged under such employer…and the nature of
the employment was the major contributing cause
of the disease. Major contributing cause must be
shown by medical evidence only, as demonstrated
by physical examination findings and diagnostic
testing.
OCCUPATIONAL DISEASES
s.440.151(2), F.S.
Whenever used in this section the term “occupational
disease” shall be construed to mean only a disease
which is due to causes and conditions which are
characteristic of and peculiar to a particular trade,
occupation, process , or employment than for the
general public. “Occupational disease” means only a
disease for which there are epidemiological studies
showing that exposure to the specific substance
involved, at the levels to which the employee was
exposed, may cause the precise disease sustained
by the employee.
PAYMENT OF MEDICAL BILLS
s.440..20, F.S.
How long does an insurer/carrier have to pay a bill?
“(2)(b) The carrier must pay, disallow, or deny all medical,
dental, pharmacy, and hospital bills submitted to the
carrier in accordance with department rule no later
than 45 calendar days after the carrier’s receipt of the
bill.
“(4) If the carrier is uncertain of its obligation to provide all
benefits or compensation, the carrier shall immediately
and in good faith commence investigation of the
employee’s entitlement to benefits under this chapter
and shall admit or deny compensability within 120 after
the initial provision of compensation or benefits…
INSURER / CARRIER
AUTHORIZATION
s.440.13(3)(d), F.S.
How long does an insurer/carrier have to authorize or
disallow a physician’s written request for treatment?
“A carrier must respond to a written request for
authorization from an authorized health care
provider by close of the third business day after
receipt of the request.”
 Prior authorization is NOT REQUIRED for
EMERGENCY SERVICES.
INSURER / CARRIER
AUTHORIZATION
(continued)
s.440.13(3)(i), F.S.
“A carrier must respond to a written request for
specialist consultations, surgical operations,
physiotherapeutic or occupational therapy
procedures, X-ray examinations or special
diagnostic or laboratory tests that cost more
than $1000 within 10 days after receipt of the
request.”
 Completion and submission of the
DFS-F5-DWC-25 is considered a written
request for authorization of treatment.
FORM DWC-25
Rule 69L-7.602, F.A.C.
DFS-F5-DWC-25 -- Florida Workers’
Compensation Uniform Medical
Treatment/Status Reporting Form
(adopted for use July 4, 2004)
A copy of the DWC-25 can be obtained from the
Division website at the following link:
http://www.fldfs.com/wc/pdf/DWC-25.pdf
FORM DWC-25
s.440.13(4)(a), F.S.
“Any health care provider providing necessary
remedial treatment, care, or attendance to any
injured worker shall submit treatment reports to
the carrier in a format prescribed by the
department.”
 The format prescribed by the
department is the Form DFS-F5DWC-25 (DWC-25).
FORM DWC-25
s.440.13(4)(a), F.S.
“A claim for medical or surgical treatment is not
valid or enforceable …unless, by the close of
the third business day following the first
treatment, the physician providing treatment
furnishes to the employer or carrier…”
a Form DWC-25
An insurer/carrier may disallow payment for services
if the health care provider does not submit a Form
DWC-25, pursuant to Rule 69L-7.602, F.A.C.
FORM DWC-25
Rule 69L-7.602, F.A.C.
 Insurers and providers shall utilize ONLY the
Form DWC-25 for physician reporting of the
injured employee’s medical treatment / status.
 Any other reporting form MAY NOT be used in
lieu of or supplemental to the Form DWC-25
Therefore, the physician is not required to
complete any other insurer/carrier forms.
FORM DWC-25
Rule 69L-7.602, F.A.C.
The Form DWC-25:
 Must be signed by the authorized physician
 Does not replace physician notes, medical
records or required billing forms
 Information must be consistent with medical
notes, medical records, diagnostic testing, etc.
 Becomes a part of the patient’s medical record
maintained by the physician
 Must be submitted to the employer upon request
FORMS SUBMITTED TO CARRIER
Rule 69L-7.602, F.A.C.
Health Care Providers who render direct
billable services shall submit to the carrier a
medical bill for reimbursement of services
using the Form DFS-F5-DWC-9 (CMS 1500)
regardless of employment arrangement.
A copy of the DFS-F5-DWC-9 can be obtained
from the CMS website:
http://www.cms.hhs.gov/cmsforms/
PROVISION OF MEDICAL RECORDS
s.440.13(4)(b), F.S.
Medical records must be produced upon request.
“Upon the request of the department, each medical
report or bill obtained or received by the employer,
the carrier, or the injured employee…, including any
report of an examination, diagnosis , or disability
evaluation, must be produced by the health care
provider to the department pursuant to rules
adopted by the department.”
 Health care providers who willfully refuse to
provide medical records or discuss the medical
condition of the injured employee are subject to
the penalties set forth in s.440.13(8)(b), F.S.
PROVISION OF MEDICAL RECORDS
s.440.13(4)(b), F.S.
“The health care provider shall also furnish
to the injured employee or his or her
attorney and the employer or carrier or its
attorney, on demand, a copy of his or her
office chart, records, and reports, and may
charge the injured employee no more than
50 cents per page for copying the records
and the actual direct cost to the health care
provider or health care facility for x rays,
microfilm, or any other nonpaper records..”
PHYSICIAN-PATIENT PRIVILEGE
s.440.13(4)(c), F.S.
A “release of information” is not required for the
health care provider to release medical records,
unless otherwise specified in the Florida Statutes.
“An employee who reports an injury or illness
alleged to be work-related waives any physicianpatient privilege with respect to any condition or
complaint reasonably related to the condition for
which the employee claims compensation.”
“Release of medical information by the health care
provider or other physician does not require the
authorization of the injured employee.”
INDEPENDENT MEDICAL
EXAMINATIONS (IME)
s.440.13(5)(a), F.S.
The physician performing the IME shall complete:
 A physical examination of the injured employee
 A review of medical records
 Determination of functional limitations and
restrictions
 Calculation of Permanent Impairment Rating if at
Maximum Medical Improvement
 Report to Carrier and Employee (a Form DWC-25
and written medical report)
INDEPENDENT MEDICAL
EXAMINATIONS (IME)
s.440.13(5)(a), F.S.
“In any dispute concerning overutilization, medical
benefits, compensability, or disability under this
chapter, the carrier or the employee may select an
independent medical examiner.”
 Although a physician may be certified as an EMA,
when an IME is requested the EMA is functioning
as health care provider, not as an EMA.
INDEPENDENT MEDICAL
EXAMINATIONS (IME)
s.440.13(5)(a), F.S.
“If the parties agree, the examiner may be a
health care provider treating or providing other
care to the employee.”
“The independent medical examiner may not
provide follow-up care if such recommendation
for care is found to be medically necessary.”
INDEPENDENT MEDICAL
EXAMINATIONS (IME)
s.440.13(5)(a), F.S.
“The employer and employee shall be entitled to
only one independent medical examination per
accident and not one independent medical
examination per medical specialty.”
“The party requesting and selecting the
independent medical examination shall be
responsible for all expenses associated with
said examination…”
IME NO-SHOW PROVISIONS
FOR PAYMENT
s.440.13(5)(d), F.S.
“If the employee fails to appear for the independent
medical examination scheduled by the employer or
carrier …the employee is barred from recovering
compensation for any period during which he or
she has refused to submit to such examination.”
“Further, the employee shall reimburse the
employer or carrier 50 percent of the physician’s
cancellation or no-show fee…”
REIMBURSEMENT DISPUTES
s.440.13(7), F.S.
What is a health care provider to do if he/she is
improperly reimbursed for services?
A health care provider may file a petition for
reimbursement dispute resolution with the
Division, pursuant to s.440.13(7), F.S. and
Rule 69LA-31, F.A.C.
The form for filing a Petition for Resolution of
Reimbursement Dispute may be printed from
the following link:
http://www.fldfs.com/wc/pdf/DFS-3160-0023.pdf
REIMBURSEMENT DISPUTES
s.440.13(7), F.S.
“Any health care provider…who elects to contest the
disallowance or adjustment of payment by a carrier
under subsection (6) must, within 30 days after
receipt of notice of disallowance or adjustment of
payment, petition the Division to resolve the dispute.”
“The petition must be accompanied by all documents
and records that support the allegations contained in
the petition. Failure of a petitioner to submit such
documentation to the Division results in dismissal of
the petition. “
CARRIER UTILIZATION REVIEW
s.440.13(6), F.S.
All insurer/carrier’s are responsible to perform
utilization review.
“Carriers shall review all bills, invoices, and other
claims for payment submitted by health care
providers in order to identify overutilization and
billing errors…”
“If a carrier finds that overutilization of medical
services or a billing error has occurred…it must
disallow or adjust payment for such services…”
OVERUTILIZATION,
STATUTE OR RULE VIOLATIONS,
HCP PENALTIES / SANCTIONS
s.440.13(8)(b), F.S.
“If the Division determines“ that a health care
provider has engaged in a pattern or practice of
overutilization or a violation of this chapter or
rules adopted by the Division, including a pattern
or practice of providing treatment in excess of the
practice parameters or protocols of treatment, it
may impose one or more…penalties.”
DIVISION OF WORKERS’
COMPENSATION JURISDICTION
s.440.13(11)(c), F.S.
“The Division has exclusive jurisdiction to
decide any matters concerning reimbursement,
to resolve any overutilization dispute under
subsection (7), and to decide any question
concerning overutilization under subsection (8)
which question or dispute arises after January
1, 1994.”
POTENTIAL PROVIDER PENALTIES
s.440.13(8)(b), F.S.
1. An order barring the provider from payment under
this chapter.
2. Deauthorization of care under review.
3. Denial of payment for care rendered in the future.
4. Decertification of a health care provider as an
expert medical advisor …
5. A fine assessed by the Division not to exceed
$5000 per instance of overutilization or violation.
6. Notification of and review by the appropriate
licensing authority.
WITNESS (Deposition) FEES
s.440.13(10), F.S.
What reimbursement is made to the health care
provider acting as a witness?
“Any health care provider who gives a deposition
shall be allowed a witness fee. The amount
charged by the witness may not exceed $200 per
hour. An expert witness who has never provided
direct professional services to a party but has
merely reviewed medical records and provided
an expert opinion or has provided only direct
professional services that were unrelated to the
workers’ compensation case may not be allowed
a witness fee in excess of $200 per day. “
PROVIDER AUDITS
s.440.13(11)(a), F.S.
What happens to the health care provider who
fails to comply with the laws and rules that
apply to Florida workers’ compensation?
“The Division of Workers’ Compensation may
investigate health care providers to determine
whether providers are complying with this chapter
and with rules adopted by the Division…If the
Division finds that a health care provider has
improperly billed, overutilized, or failed to comply
with Division rules or the requirements of this
chapter…may impose penalties as set forth in
subsection (8) or other sections of this chapter.
REIMBURSEMENT FOR MEDICAL
SERVICES
s.440.13(12)(a), F.S.
How is the reimbursement schedule determined?
“The panel (Three Member Panel) shall determine
statewide schedules of maximum reimbursement
allowances for medically necessary treatment, care,
and attendance provided by physicians …and durable
medical equipment.”
“An individual physician, hospital…shall be reimbursed
either the agreed-upon contract price or the maximum
reimbursement allowance in the appropriate
schedule.”
REIMBURSEMENT FOR MEDICAL
SERVICES
s.440.13(12)(b), F.S.
“4. Maximum reimbursement for a physician licensed
under chapter 458 or 469L shall be increased to 110
percent of the reimbursement allowed by Medicare,
using appropriate codes and modifiers or the medical
reimbursement level adopted by the three-member panel
as of January 1, 2003, whichever is greater.”
“5. Maximum reimbursement for surgical procedures
shall be increased to 140 percent of the reimbursement
allowed by Medicare or the medical reimbursement level
adopted by the three member panel as of January 1,
2003, whichever is greater.”
REIMBURSEMENT
Rule 69L-7.020, F.A.C.
Where can a health care provider locate the
maximum reimbursement allowances for services?
“The Florida Workers’ Compensation Health
Care Provider Reimbursement Manual, 2005
Edition…contains reimbursement policies ,
guidelines, codes and maximum reimbursement
allowances for services and supplies provided by
health care providers.”

The appropriate Health Care Provider
Reimbursement Manual is determined
by the manual in effect on the date the
service is provided.
REIMBURSEMENT
Rule 69L-7.020, F.A.C.
Reimbursement manuals may be viewed on or
printed from the Division website:
www.fldfs.com/wc
Location of Reimbursement
Manuals, Forms and Rules
www.fldfs.com/WC/
EXPERT MEDICAL ADVISOR
(EMA)
 How does a physician become a Florida
workers’ compensation Expert Medical
Advisor?
 What are the Expert Medical Advisor’s
duties and responsibilities within the Florida
Workers’ Compensation system?
 Who can select the Expert Medical Advisor?
EXPERT MEDICAL ADVISORS
s.440.13(9), F.S.
How does a physician become an
Expert Medical Advisor?
 The physician must meet the qualifications specified
in Rule 69LA-30.003, F.A.C.
 The physician must submit a completed application
for Expert Medical Advisor Certification to the
Division.
The application may be printed from the following link:
http://www.fldfs.com/wc/pdf/DFS-3160-0021.pdf
EXPERT MEDICAL ADVISOR
CERTIFICATION
Rule 69LA-30, F.A.C.
Expert Medical Advisor certification requires that the
physician attest to knowledge of the Florida Statutes
related to workers’ compensation, specifically
Sections 440.02, 440.09, 440.093, 440.102, 440.105,
440.13, 440.134, 440.15(3), 440.15(5), 440.151,
440.20 and 440.091 and knowledge of the Florida
Administrative Code Rules 69L-7.602 and 69L-7.020
or complete this tutorial.
EXPERT MEDICAL ADVISORS
Rule 69LA-30.003, F.A.C.
To be certified as an Expert Medical Advisor, a
physician shall meet the following qualifications:
 Must have been certified as a health care provider
by the Division for not less than 12 months prior to
the date of application; and
 Must hold valid licensure, issued by the Florida
Department of Health, with “clear and active” status;
and
 Must hold specialty-board certification or specialtyboard eligibility; and
EXPERT MEDICAL ADVISORS
Qualifications (continued)
 Must demonstrate experience in the assignment of
permanent impairment ratings greater than zero
(0%); and
 Must demonstrate experience in performing
independent medical examinations; and
 Must have completed twenty hours of continuing
medical education, specifically related to the
practitioner’s field of specialty, within two years
prior to the date of application; and
 Must possess knowledge of the Florida Statutes
and Florida Administrative Code related to workers’
compensation.
EXPERT MEDICAL ADVISORS
Rule 69LA-30.004, F.A.C.
Throughout the certification period, the Expert
Medical Advisor shall notify the Division:
 If specialty-board certification has expired
 If Florida Department of Health license status is
changed from “clear and active”
 Of any change in address or contact information
EXPERT MEDICAL ADVISORS
Rule 69LA-30.007, F.A.C.
CONFLICT OF INTEREST
“Upon receiving notice of selection by the Division
or judge of compensation claims as an Expert
Medical Advisor the physician shall disclose any
conflict of interest related to the case for which the
physician was selected and shall decline selection
as an Expert Medical Advisor.”
 An Expert Medical Advisor shall decline selection
as an EMA if a conflict of interest exists.
EXPERT MEDICAL ADVISORS
s.440.13(9), F.S.
• An EMA may ONLY be contracted by the
Division or Judges of Compensation
Claims
• EMAs are contracted to settle disputes
related to:
- Reimbursement allowances
- Differing health care provider opinions
- Medical necessity of services rendered
EXPERT MEDICAL ADVISORS
s.440.13(9), F.S.
“The Division shall certify expert medical advisors
in each specialty to assist the Division and the
judges of compensation claims…”
“As a prerequisite for certification or recertification,
the Division shall require, at a minimum, that the
expert medical advisor have specialized workers’
compensation training or experience under the
workers’ compensation system of this state and
board certification or board eligibility.”
EXPERT MEDICAL ADVISORS
s.440.13(9), F.S.
“The Division shall contract with one or more
entities that employ, contract with, or otherwise
secure expert medical advisors to provide peer
review or expert medical consultation, opinions,
and testimony to the Division or to a judge of
compensation claims in connection with
resolving disputes relating to reimbursement,
differing opinions of health care providers, and
health care and physician services rendered
under this chapter, including utilization issues.”
EXPERT MEDICAL ADVISORS
s.440.13(9), F.S.
“Expert medical advisors contracting with the
Division shall, as a term of such contract, agree
to provide consultation or services in
accordance with the timetables set forth in this
chapter and to abide by rules adopted by the
Division…pertaining to procedures for review of
services rendered by health care providers and
preparation of reports and testimony or
recommendations for submission to the
Division or the judge of compensation claims.”
EXPERT MEDICAL ADVISORS
s.440.13(9), F.S.
“If there is a disagreement in the opinions of the
health care providers…The opinion of the expert
medical advisor is presumed to be correct unless
there is clear and convincing evidence to the
contrary as determined by the judge of
compensation claims.”
“The expert medical advisor appointed to conduct
the evaluation shall have free and complete
access to the medical records of the employee.”
EXPERT MEDICAL ADVISORS
s.440.13(9)(d), F.S.
“The expert medical advisor must complete his or
her evaluation and issue his or her report to the
Division or to the judge of compensation claims
within 15 days after receipt of all medical records.
The expert medical advisor must furnish a copy of
the report to the carrier and to the employee.”
 The expert medical advisor shall submit an
accurately completed Form DWC-25 to the insurer/
carrier by close of the following business day
when a patient physical examination is performed.
EXPERT MEDICAL ADVISORS
s.440.13(9)(f), F.S.
“The party ordering the services of an expert medical
advisor to resolve a dispute must compensate the
advisor for his or her time in accordance with a
schedule adopted by the Division.”
“If the employee prevails in a dispute …based on the
expert medical advisor’s findings, the employer or
carrier shall pay for the costs…”
“The Division may assess a penalty not to exceed
$500 against any carrier that fails to timely compensate
an advisor in accordance with this section.”
EXPERT MEDICAL ADVISORS
s.440.13(9)(f), F.S.
Who reimburses for the services of an
Expert Medical Advisor?
The party ordering the services of an expert
medical advisor to resolve a dispute must
compensate the advisor for his or her time .
If the employee prevails in a dispute …based
on the expert medical advisor’s findings, the
employer or carrier shall pay for the costs…
 An Expert Medical Advisor shall submit
his/her bill on an invoice approved by the
Judge of Compensation Claims or the
Division.
EXPERT MEDICAL ADVISORS
Rule 69LA-30.008(5), F.A.C.
REIMBURSEMENT SCHEDULE FOR SERVICES
CONTRACTED BY:
Judges of Compensation Claims - $300.00
per hour for no more than 8 hours per case
Division of Workers’ Compensation- $200.00
per hour for no more than 8 hours per case
REMOVAL OF PHYSICIANS FROM
Division LIST OF CERTIFIED
HEALTH CARE PROVIDERS
s.440.13(13), F.S.
The Division may remove a provider from the
Division’s list of certified health care providers or
Expert Medical Advisors.
“The Division shall remove from the list of physicians…
authorized to provide remedial treatment, care and
attendance under this chapter the name of any
physician…found after reasonable investigation to have:
(a) Engaged in professional or other misconduct or
incompetency in connection with medical services
rendered under this chapter;
REMOVAL OF PHYSICIANS FROM
Division LIST (continued)
s.440.13(13), F.S.
(b) Exceeded the limits of his…professional
competence… or to have made materially false
statements regarding his…qualifications in
his…application;
(c) Failed to transmit copies of medical reports to the
employer or carrier, or failed to submit full and
truthful medical reports of all his…findings to the
employer or carrier as required…;
(d) Solicited, or employed another to solicit for himself
…professional treatment, examination, or care of an
injured employee in connection with any claim…;
REMOVAL OF PHYSICIANS FROM
Division LIST (continued)
s.440.13(13), F.S.
(e) Refused to appear before, or to answer upon
request of, the Division…any legal question, or to
produce any relevant book or paper concerning
his…conduct under any authorization granted to
him…under this chapter;
(f) Self-referred in violation of this chapter or other
laws of this state; or
(g) Engaged in a pattern or practice of overutilization
or a violation of this chapter or rules adopted by
the Division…
Florida Statutes 440.134
WC Managed Care Arrangements
The following list provides the statutes related
to Workers’ Compensation Managed Care
Arrangements, including a brief description for
each subsection.
• 440.134(1)(g): Definition of WCMCA
• 440.134(1)(i): Definition of medical care
coordinator
• 440.134(1)(j): Definition of provider network
• 440.134(1)(k): Definition of primary care provider
Florida Statutes 440.134
WC Managed Care Arrangements
(continued)
• 440.134(4):
AHCA authorization as WCMCA
• 440.134(6):
Plan of Operation elements WCMCA
• 440.134(7):
Provision of Records to insurer/
carrier - WCMCA
• 440.134(8):
Training and education of HCP
and Administrative Staff
Florida Statutes 440.134
WC Managed Care Arrangements
(continued)
Complete information regarding Workers’
Compensation Managed Care
Arrangements may be viewed at the
Division’s home webpage (listed under
CH. 440, FL Statutes) at the following link:
www.fldfs.com/wc
Florida Administrative Code
Rules pertaining to Medical Services
Chapter 69L
•
•
•
Rule 69L-3.0047 = Fraud Statement
Rule 69L-7.602 = Billing, Filing and Reporting
of Medical Services
Rule 69L-7.020 = Health Care Provider
Reimbursement Manual
Florida Administrative Code
Rules pertaining to Medical Services
Chapter 69L
• Rule 69LA-29 - Health Care Provider Certification
• Rule 69LA-30 - Expert Medical Advisor Certification
• Rule 69LA-31 - Reimbursement Disputes
Florida Administrative Code
Florida Administrative Code rules may be viewed
at or printed from the following Internet address:
http://fac.dos.state.fl.us/
? QUESTIONS ?
Contact the Specialist On-Call
(850) 413-1613
Workers’ Compensation Medical Services Unit
CONGRATULATIONS!
YOU HAVE SUCCESSFULLY
COMPLETED THE EXPERT
MEDICAL ADVISOR TUTORIAL
This concludes the Florida Workers’
Compensation Tutorial for Expert
Medical Advisors. Completion of this
tutorial fulfills the Expert Medical
Advisor certification criteria requiring
the physician to attest to familiarity with
the rules and statutes relating to the
provision of benefits and services in the
Florida Workers’ Compensation system.